1. Public Health Agency of Canada (PHAC)
Collaboration during multi-jurisdictional foodborne outbreak investigations and response
Canadian Food Inspection Agency (CFIA)
Lorraine Haskins, Food Safety Recall Specialist
Office of Food Safety and Recall
Public Health Agency of Canada (PHAC)
Popy Dimoulas-Graham, Senior Epidemiologist
Outbreak Management Division, Centre for Food-borne, Environmental and Zoonotic Infectious Diseases (CFEZID)
Tuesday, June 28, 2011
Canadian Institute of Public Health Inspectors (CIPHI) Conference 2011

2. Overview Emerging Trends Foodborne Illness Outbreak Response Protocol
Stakeholders and roles
Steps of an outbreak investigation
Salmonella Chester (2010)
Salmonella Carrau (2009)
Especially true following high profile outbreaks like the listeriosis outbreak in 2008 and with the advent of widespread internet use and social media. Rapid pace of communications and information demands.

3. Emerging trends in foodborne outbreaks
Changes in food production – mega farms and production (centralization), global sourcing
Increase in widely distributed outbreaks
Changes in eating patterns – chicken, healthier, ready-to-eat
Increase in produce, ready-to-eat related outbreaks
Increased capacity for detection – PFGE, MLVA
Increase identification of outbreaks that may not cluster in space
Aging population
More severe outcomes
I represent…
Primarily foodborne but enteric diseases – animal contact such as petting zoos, waterborne outbreaks, person to person transmission at a daycare – more often than food, restricted to one jurisdiction so not involved. Foodborne, frequently multi-jurisdictional – involved in 50 outbreak issues each year with potential to become multi-jurisdictional
Before development of pathogen-specific surveillance, foodborne disease outbreaks were typically recognized because of the occurrence of large numbers of illnesses among persons with a known common exposure. The development of pathogen-specific surveillance through public health laboratories has allowed the detection of widely dispersed outbreaks caused by commercially distributed food products. Outbreaks identified through pathogen-specific surveillance are initially recognized as clusters of cases defined by subtype characteristics. Distribution of these cases by time, space, and personal characteristics provides important clues about whether the cases are likely to represent an outbreak from a common source of exposure. However, only a systematic investigation of the cluster can confirm whether it actually is an outbreak and, if so, whether it is a foodborne disease outbreak.
Public Health Agency of Canada | Agence de la santé publique du Canada 3

4. Globalization – wide commercial distribution, air travel, increased international trade
Geographically dispersed cases, introduction of new pathogens
Examining the ingredients in a taco paints a picture of the globalization of our food production network
group of archtecture students that deconstructed a taco to demonstrate the effect of globalization on the food we eat
goal was to map the ‘tacoshed’
According to the class findings, within a single taco, the ingredients had traveled a total of 64,000 miles, or just over two and a half times the circumference of the earth.
The changing picture of how we get our food impacts the nature of outbreaks
Multi-jurisdictional collaboration!

5. Outbreak Truths Every outbreak is different
No universally accepted approach to an outbreak
Outbreak response varies with the outbreak, the agencies involved, available resources, and the surrounding circumstances (e.g., etiologic agent, number of cases, and likely source of exposure, population affected)
Investigation activities are rarely linear
Communication or implementation of control measures, occur repeatedly throughout an investigation

6. Canada’s Foodborne Illness Outbreak Response Protocol (FIORP) 2010:
Framework to guide multi-jurisdictional collaboration for identification and response
Defines roles and responsibilities
Describes guiding principles and operating procedures
Focus on information exchange, communication and collaboration between agencies
Timely and clear communication and coordination between partners is one of the most critical challenges in outbreak investigation. Protocol to guide very helpful – worked out in advance as part of planning and preparation.
Bringing multiple agencies with different mandates together can be challenging, and it’s important to bring responsible parties together to mutually agree on a framework, and Canada has done just that...
The principal framework document which guides multi-jurisdictional collaboration in response to food-borne illness outbreaks in Canada is the Foodborne Illness Outbreak Response Protocol (FIORP)
Developed by the Public Health Agency of Canada (PHAC), Health Canada (HC), and the Canadian Food Inspection Agency (CFIA), in consultation with provincial/territorial (P/T) stakeholders, to enhance the collaboration and overall effectiveness of response during multi-jurisdictional food-borne illness outbreaks
Defines guiding principles, roles and responsibilities and operating procedures for outbreak investigation that cross provincial jurisdictions
Some provinces (eg. Alberta, BC, Ontario, MB, NS also have specific protocol guidelines for their provinces as well)
Full document can be found on PHAC website
Remember, JUST A FRAMEWORK... No two outbreaks are exactly the same
The structure and leadership of the outbreak team will vary depending on the nature of the outbreak, how it was detected, characteristics of the pathogen and the distribution of cases
eg. detected at the local level, clustered mainly within a geographic region, vs. widely dispersed outbreak detected via laboratory diagnostics
Responsibilities for responding to food-borne illness outbreaks may be shared between federal/provincial/territorial (F/P/T) and local/regional jurisdictions.  The response to such situations involves collaboration and cooperation among all those involved. 

7. Multi-jurisdictional Collaboration
Local and regional public health authorities
Provincial/territorial governments (health & agriculture)
Public Health Agency of Canada
Health Canada (HC)
Canadian Food Inspection Agency (CFIA)
International health authorities and food safety agencies
Bringing multiple agencies with different mandates together can be challenging, and it’s important to bring responsible parties together to mutually agree on a framework, and Canada has done just that...
The principal framework document which guides multi-jurisdictional collaboration in response to food-borne illness outbreaks in Canada is the Foodborne Illness Outbreak Response Protocol (FIORP)
Developed by the Public Health Agency of Canada (PHAC), Health Canada (HC), and the Canadian Food Inspection Agency (CFIA), in consultation with provincial/territorial (P/T) stakeholders, to enhance the collaboration and overall effectiveness of response during multi-jurisdictional food-borne illness outbreaks
Defines guiding principles, roles and responsibilities and operating procedures for outbreak investigation that cross provincial jurisdictions
Some provinces (eg. Alberta, BC, Ontario, MB, NS also have specific protocol guidelines for their provinces as well)
Full document can be found on PHAC website
Remember, JUST A FRAMEWORK... No two outbreaks are exactly the same
The structure and leadership of the outbreak team will vary depending on the nature of the outbreak, how it was detected, characteristics of the pathogen and the distribution of cases
eg. detected at the local level, clustered mainly within a geographic region, vs. widely dispersed outbreak detected via laboratory diagnostics
Responsibilities for responding to food-borne illness outbreaks may be shared between federal/provincial/territorial (F/P/T) and local/regional jurisdictions.  The response to such situations involves collaboration and cooperation among all those involved. 

8. Current Information Exchange Among Food Safety Partners
Partners and flow of information.
Red = primary points of contact.
Blue = partners from whom we receive information through our primary partners.
Grey = sources of information that we receive but for the most part do not exchange information with
Information exchange is not linear but varied; ongoing; demonstrates how information about a potential cluster or outbreak can originate from many sources.

9. PHAC’s Role in Outbreak Response
Monitor for and respond to enteric disease outbreaks that involve more than one P/T or country
Lead multi-jurisdictional outbreaks involving more than one P/T or country
Coordinate epidemiological investigation and information sharing
Provide consultation, content expertise as requested by P/Ts
Contribute to international foodborne outbreak investigations
Provide epidemiological content expertise to CFIA and Health Canada
Chair outbreak debriefing sessions
Lead or contribute to the documentation of the outbreaks through peer review 9

10. CFIA Role in Outbreak Response
Food safety investigations
Food testing
Recall activities
Regulatory compliance and enforcement activities
Knowledge of the food production and food distribution system
CFIA delivers all federal inspection and enforcement services related to food under the authority of 13 federal acts that address all stages of the food continuum. Not only does CFIA inspect foods, but also the seed, livestock feed, fertilizers, plants and animals on which a safe food supply depends. CFIA’s contribution to the investigation and control of foodborne illness outbreaks includes its food safety investigation, testing and recall activities, as well as its regulatory compliance and enforcement activities.
Food Safety investigation - (for foods imported or shipped interprovincially, or manufactured in an establishment under CFIA’s jurisdiction)
Food testing – routine monitoring programs and samples from establishment under investigation, in distribution facilities.
Recall – health hazard alert issued, communications regarding recalls, recall effectiveness checks in collaboration with public health, detain.
Regulatory compliance and enforcement activities 10

11. Health Canada Role in Outbreak Response
Establish policies/guidance and regulations related to food safety
Set standards
Provide Risk Assessments
Provide advice and information on food safety
Provide applied research and surveillance to support activities, including Risk Management
Laboratory testing (Reference Services/surge capacity)
Collaborate with government and other partners within Canada and internationally 11

12. Steps in an Outbreak Investigation
Determine existence of an outbreak
Confirm diagnosis
Assemble team
Implement immediate control measures
Develop case definition & find cases
Analyse time, place, person data
Generate hypothesis
Test hypothesis
Implement prevention & control measures
Disseminate findings, conduct evaluation
‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines
Speed and accuracy
Flexible and innovative, yet systematic
Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators
best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten
Skipping to epi – hypothesis generation, weight of evidence

13. Determine Existence of an Outbreak
Triggers: Human Illness
Local/regional officials identify outbreak
National or P/T surveillance activities identify an outbreak (including lab)
International outbreak with the potential to affect Canada
Triggers: Food product
Agent or pathogen pattern from food is matched with agent or pathogen pattern in human
NESP
Administered by NML and CFEZID
Weekly, aggregate, laboratory-based
Purpose
Monitor trends over time and geography
Detect increases across jurisdictions
Pathogens (under review)
Salmonella, Campylobacter, Shigella, Vibrio, E. coli, Yersinia, Giardia, Cryptosporidium, Entamoeba, Rotavirus, Norovirus
‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines
Speed and accuracy
Flexible and innovative, yet systematic
Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators
best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten
Skipping to epi – hypothesis generation, weight of evidence 13

14. Assemble Team Often includes: Provincial Public Health
Provincial Laboratory
National Microbiology Laboratory, PHAC
CFIA
Health Canada
Outbreak Management Division, PHAC
U.S. CDC and FDA
‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines
Speed and accuracy
Flexible and innovative, yet systematic
Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators
best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten
Skipping to epi – hypothesis generation, weight of evidence 14

15. Planning and Preparation
Identify the players and their roles
Standard processes
Outbreak information management, communication, escalation, recovery and follow-up post outbreak
Outbreak tools
Case interview forms, databases, communication templates

16. Develop case definition & find cases
Salmonella Chester (2010)
Confirmed case:
Laboratory confirmation of Salmonella Chester with PFGE pattern ChesXAI.0007/ChesBNI.0002 or ChesXAI.0007/ChesBNI.0003 AND/OR Laboratory confirmation of Salmonella Chester with an epidemiological link to purchase or consumption of head cheese; AND a lab-confirmed date on or after June 1, 2010; AND the individual is a resident of or visitor to Canada.
Probable case:
Laboratory confirmation of Salmonella Chester with PFGE and exposure information pending; AND a lab-confirmed date on or after June 1, 2010; AND the individual is a resident of or visitor to Canada.
‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines
Speed and accuracy
Flexible and innovative, yet systematic
Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators
best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten
Skipping to epi – hypothesis generation, weight of evidence 16

17. Analyse data (time, place, person)
‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines
Speed and accuracy
Flexible and innovative, yet systematic
Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators
best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten
Skipping to epi – hypothesis generation, weight of evidence 17

18. Hypothesis Generation
Review literature and surveillance data
Person, place, time characteristics of case data
Investigation techniques based on resources & population affected
Exposure assessment and comparison with food consumption surveys
Dynamic process
Hypothesis generation should begin early in an outbreak investigation
narrow the focus of the investigation and use time and resources most effectively
Key steps in hypothesis generation include the following:
Reviewing previously identified risk factors and exposures for the disease;
Examining the descriptive epidemiology of cases to identify person, place, or time characteristics that might suggest particularly likely exposures; and
Interviewing in detail the affected persons or a sample of affected persons to identify unusual exposures or commonalities among cases ( ).
Cluster investigation techniques
Should be based on resources and populations
Ex. dynamic cluster investigation
initial cases in a recognized cluster are interviewed with a detailed exposure history questionnaire. As new suspicious exposures are suggested during the interviews (i.e., are reported among 5-10 cases), initial cases are systematically re- interviewed to uniformly assess their exposure and the suspicious exposure is added to the interview of subsequently identified cases.
*other examples For agencies that routinely interview ALL cases with a detailed exposure questionnaire, dynamic cluster investigation can be initiated as soon as a cluster is recognized. Such an approach results in improved recall because cases are more likely to remember exposures when specifically questioned about them.
For agencies that do not have sufficient resources to conduct detailed exposure history interviews for every case, a two-step interviewing process may be the best alternative approach. All cases are interviewed to collect information about a limited set of “high-risk” exposures specific to the pathogen. When a cluster becomes apparent, all cases in the cluster are then interviewed using a detailed exposure questionnaire following the “dynamic cluster investigation” approach ( ).
For agencies that do not have sufficient resources to conduct detailed interviews with all cases in a cluster, hypothesis- generating interviews can be undertaken with a subset of cases after a cluster becomes obvious. Exposures reported by a substantial proportion of these cases can then be studied

19. Weight of Evidence for Action
Varies widely
Combination of epidemiological, laboratory and traceback investigations
Strength relies heavily on quality and specificity of information and samples collected
Scientific evidence needed to proceed with an action to implement control measures as quickly as possible and prevent further illnesses varies widely, and is usually based on a combination of different factors.

20. Weight of Epidemiological Evidence
Strong analytical study not always needed
Descriptive epi plus pathogen identified in food
Descriptive epi plus traceback to unusual vehicle (e.g., frozen mice fed to corn snakes)
Is it plausible that a given food item is the vehicle of infection?
Is a given food item consistently reported across different populations?
Is the temporal and/or spatial clustering of cases consistent with the availability/distribution of a particular food product?
Does the information provided indicate a single specific food product as the vehicle of infection?
How strong is the statistical association between a given food item and the foodborne illness?
Do strain typing results support the epidemiology?
Have alternative hypotheses been ruled out?

21. Salmonella Chester (2010) Multi-provincial outbreak of S. Chester
Rare serotype of Salmonella in Canada
Between July 5 & Sept 2, 2010, a total of 33 confirmed cases with matching PFGE patterns were reported to PHAC from 4 provinces
Median age = 75 years; 55% male
8 (31%) case hospitalized; no deaths reported
Identified headcheese as the source of the outbreak
PHAC to discuss their role during outbreak 21

22. Salmonella Chester (2010) – CFIA
Food Safety Investigation Components
Confirm the product and affected firm
Packaged product sold at delis
Recall of the head cheese directly associated to the illnesses
Determine the extent of the problem
Continue the FSI at the manufacturer level to
Identify other potentially affected head cheese
Identify other potentially affected products
Process and records review
Recall of additional head cheese and additional products
Corrective actions identified and implemented
‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines
Speed and accuracy
Flexible and innovative, yet systematic
Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators
best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten
Skipping to epi – hypothesis generation, weight of evidence 22

23. Salmonella Chester (2010) – Health Canada
Participated in OICCs
Conducted 7 risk assessments associated with this event
Provided consultation on sampling
Participated in NEOC
Participated in Thermal Processing Working Group to evaluate manufacturer’s smoker/cooker validation data
‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines
Speed and accuracy
Flexible and innovative, yet systematic
Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators
best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten
Skipping to epi – hypothesis generation, weight of evidence 23

24. Salmonella Carrau (2009) Joint investigation between Canada and U.S.A.
Rare serotype of Salmonella in Canada
Between March 12 & Apr 30, 2009, a total of 35 confirmed cases with matching PFGE patterns were reported to PHAC from 8 provinces
Median age = 23 years; 57% female
7 (23%) case hospitalized; 2 deaths
Case-control study conducted
PHAC to discuss their role during outbreak 24

25. Salmonella Carrau (2009) – CFIA
Food Safety Investigation Challenges
No label and lot code available
Short shelf-life
Traceback initiated using invoices over large timeframe
Various Public Health provided some invoices, grocery receipt and menus.
Collaboration with US FDA for traceback
No single point of origin: more than one possible supplier and country
‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines
Speed and accuracy
Flexible and innovative, yet systematic
Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators
best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten
Skipping to epi – hypothesis generation, weight of evidence 25

26. Salmonella Carrau (2009) – Health Canada
Monitored situation as information became available
Participated in OICC
No assessments required
‘The ‘steps in investigating an outbreak’ emphasizes the need to work systematically through each outbreak investigation, allowing activities to consciously be omitted or rearranged, but not overlooked in the urgency of the moment’  CIFOR guidelines
Speed and accuracy
Flexible and innovative, yet systematic
Maintaining close communication and coordination among epidemiologic, environmental health, and laboratory investigators
best way to ensure concurrent activities do not interfere with each other and important investigation steps are not forgotten
Skipping to epi – hypothesis generation, weight of evidence 26

27. Thank-you. Questions? Lorraine Haskins, Food Safety Recall Specialist, CFIA Enrico Buenaventura, Section Head, Health Canada Popy Dimoulas-Graham, Senior Epidemiologist, PHAC